Further steps into dentistry. Учебное пособие для студентов стоматологического факультета

Disorders of the Lips, Mouth, and Tongue Lips

An acute swelling of the lip may be angioedema. Brownish-black melanin pigmentation spots in association with GI polyposis occur in the Peutz-Jeghers syndrome. Exfoliative cheillitis is a chronic desquamation of the superficial mucosal cells; if it persists despite abstention from very hot or irritating foods and alcoholic beverages and despite changes of lipstick or dentures, triamcinolone acetonide ointment should be tried. A chancre has a serosanguineous crust .

Mucocele (mucous retention cyst) found on the lower lip, is due to trauma severing the excretory ducts of the accessory salivary glands and permitting the mucin-containing saliva to escape into the tissues. A soft nodule forms. If the nodule is superficial, the overlying epithelium is thinned and assumes a bluish tinge. Treatment is excision.

Tiny painful vessels characterize 2 common disorders: herpes labialis (cold sore), found on the vermillion border of the skin, and recurrent aphthous ulcers (canker sores), on the inner aspects of the lips.

Cheilosis (angular cheilitis) is characterized by fissuring and dry scaling of the skin and vermillion surface of the lips and angles of the mouth. The condition is infrequently associated with deficiency of some of the B vitamins, particularly riboflavin and pyridoxine, and frequently accompanies other clinical signs of avitaminosis. One must also consider herpetic involvement, the split papule of syphilis, and the pseudocheilosis or wrinkling at the corners of the mouth accompanying loss of vertical dimension of the face (the distance between the jaws). In edentulous patients, wrinkling can be diminished by inserting dentures that separate the jaws. Loss of skin elasticity with aging normally results in overlapping of the corners of the mouth, so that saliva pools there and contributes to angular inflammation. Persistent lesions should be cultured to rule out a mycotic infection, particularly candidiasis (perleche). Mixed infections respond best to a combination of antifungal and antiinflammatory agents. High doses of vitamin B complex are beneficial if blood test indicate a deficiency.

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New words and word combinations angioedema – ангионевроти- canker sores – афтозный сто-

Buccal Mucosa

Mucosal lesions may cause dentures to hurt or fit poorly. Koplik’s spots are tiny, gray-white macules with red margins occurring during the late prodromal and early eruptive stages of measles. Aspirin burn is a painful white area of coagulated tissue caused by the local caustic action of aspirin placed against the mucosa to relieve a toothache. Wiping off the white film reveals an inflamed area. Irritation «fibroma,» composed of fibrous tissue, is not a true neoplasm. It may usually present opposite the occlusal plane where the patient chronically bites or sucks his cheek. Treatment

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is excision and breaking the habit or reducing the cusps of offending teeth. Hereditary hemorrhagic telangiectasia is characterized by localized dilated blood vessels in the oral cavity, nasal mucosa, and elsewhere. If bleeding occurs local pressure and an absorbable gelatin sponge ordinarily suffices. If not, a cautery may be used. Lichen planus often occurs with cutaneous lesions. The mucosa is characteristically netlike and hardened, with papules or erosive areas. Violet atrophic or white hyperkeratotic variations may appear on the dorsum of the tongue.

Bullae of short duration occur in various mucocutaneous disorders (eg, pemphigus and erythema multiforme), including the severe Stevens-Johnson syndrome. Behcer’s syndrome is manifested by oral as well as ocular and genital mucosal ulcers. Herpangina, characterized by vesicles in the posterior part of the mouth, and hand-foot-and-mouth disease, with small ulcerated visicles, are both due to coxsackie-viruses.

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Floor of the Mouth

This area may be the site of a cellulitis following extraction of, or root canal treatment on, an abscessed mandibular tooth. Incision, drainage, and aggressive antibiotic therapy (eg, initially, 1 gm penicillin V orally, then 500 mg q 6 h for 10 days) are indicated. An extensive sublingual infection, termed Ludwig’s angina, is very hard to palpation.

An epidermoid cyst is an inclusion cyst in the floor of the mouth (usually in the midline) or the mucobuccal fold, which is the junction of the buccal mucosa and the alveolar mucosa. The midline of the floor of the mouth is the most common location for a dermoid cyst, which has a doughy feel. All cysts should be excised and carefully examined for evidence of malignancy.

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Salivary Glands

Painless swelling of the parotid glands is often noted in hepatic cirrhosis, in sarcoidosis, in mumps, following abdominal surgery, or in association with neoplasmas or infections. The common factors may be dehydration and inattention to oral hygiene. The latter promotes the growth of large numbers of bacteria that in the absence of sufficient salivary flow ascend from the mouth into the duct of a gland. Another cause of a painful salivary gland is sialolithiasis (salivary duct stone). The submandibular glands are most commonly affected. Pain and swelling associated with eating are characteristic. Calcium phosphate stones tend to form because of the high pH and viscosity of the submandibular gland saliva, which has a high mucin content. Stones are removed by manipulation or excision.

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Autoimmune sialosis is the Mikulicz-Sjorgen syndrome, a unilateral or bilateral enlargement of the parotid and/or submandibular glands, and often the lacrimal glands. Occasionally painful, it is associated with xerostomia (dry mouth) due to impaired saliva formation, which is most common in older women.

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The Palate

Torus palatinus is a common benign overgrowth of bone (osteoma) in the midline of the hard palate where the maxillae fuse. No treatment except reassurance is required unless a dentist wishes to cover the hard palate completely with a denture. If so, surgery is required; the tissue covering a torus is thin and easily traumatized by foods.

A hole in the palate may be a congenital cleft. Clefts of the palate or lip occur once in 700 to 800 births. The cleft may vary from involvement of only the soft or hard palate to a complete cleft of both palates, the alveolar process of the maxilla, and the lip. The infant should be referred to a cleft palate team (pediatrician, orthodontist, speech pathologist, plastic surgeon, and psychologist). Causes of perforating lesions other than the congenital cleft include salivary gland tumors, the gumma of tertiary syphilis, carcinoma of the palate, and rarely, TB.

In infectious mononucleosis, petechiae may occur at the junction of the hard and soft palate. In neutropenia or agranulosis, there may be ulcerations with little inflammation. Clumps of asymptomatic red papules are seen in inflammatory hyperplasia of the palate (pseudopapillomatosis). A denture may irritate such lesions.

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The palate may be the site of Wegener’s granulomatosis (lethal midline granuloma), in which there is destruction of bone with sequestration. In AIDS, intraoral lesions of Kaposi’s sarcoma have a predilection for the palate. They begin as red-to-purple macules and progress to painful papules. Local treatment is radiation therapy or

Stomatitis

An inflammation of the mouth, often a symptom of systemic disease. Fetid breath odor and blood-tinged saliva may accompany any ulcerative lesions of the oral mucosa.

Etiology. Stomatitis may be caused by infection, trauma, dryness, irritants and toxic agents, hypersensitivity, or autoimmune conditions. Infectious agents include streptococci, gonococci, fusospirochetes, Candida albicans, Corynebacterium diphtheriae, Treponema pallidum, and the viruses of herpes simplex, varicellar-zoster, measles, and infectious mononucleosis, as well as coxsackie-virus. Stomatitis may also result from avitaminosis, particulaly lack of the B vitamin C ( as in pellagra, sprue, pernicious anemia, or scurvy);

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or from iron-deficiency anemia with dysphagia, agranulocytosis, or leukemia. Lichen planus, erythema multiforme, SLE, Behcet’s syndrome, and pemphigus vulgaris frequently present oral mucosa signs. Mechanical trauma from cheek biting, mouth breathing jagged teeth, orthodontic appliances, ill-fitting dentures, or nursing bottles with nipples that are hard or too long may produce characteristic lesions. Xerostoma resulting from drugs, the aging process, or radiation therapy predisposes the mouth to sensitivity and infection. Generalized stomatitis may follow excessive use of alcohol, tobacco, hot foods, or spices; or sensitization to tooth-paste, mouthwash, candy dyes, lipstick, and rarely dentures. Phenytoin, iodides, bismuth, mercury, barbiturates, lead, and many other drugs may produce stomatitis. Chemical stomatitis of occupational origin may be due to dyes, heavy metals, acid fumes, or metal or mineral dust. The latter 3 may also cause abrasion of the hard tissues. Mercury causes marked salivation.

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Symptoms and Signs of Stomatitis

Clinical signs vary widely according to the type of stomatitis present. Allergic stomatitis is characterized by an intense, shiny erythema with slight swelling. Itching, dryness, or burning, often present, may be due to sensitivity to foods or to lipstick.

Acute necrotizing ulcerative gingivitis (ANUG) or Vincent’s infection causes ulceronecrotic lesions of the interdental papillae that may extend to the marginal gingivae or produce painful ulcers

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of the mucous membranes. When associated with HIV infection, the ANUG rapidly becomes destructive.

Candidiasis (thrush), caused by C. Albicans, is characterized by white, slightly raised patches resembling milk curds that when removed expose a hyperemic area that may bleed slightly. This is the pseudomembranous form. The infection usually begins on the tongueandbuccalmucosaandmayspreadtothepalate,gums,tonsils, pharynx, larynx, GI tract, respiratory system, and skin. Candidiasis is common in infants; the immonosupressed; individuals receiving long-term antibiotic, corticosteroid, and antineoplastic therapy; and those with xerostoma. The chronic, erythematous (atrophic) form of candidiasis appears as a generalized redness of the oral mucosa, usually accompanied by diminished taste acuity. A third form (hypertrophic) presents as confluent, white, nonwipeable areas.

Pseudomembranous (or membranous) stomatitis, an inflammatory reaction that produces a membrane-like exudate, may be caused by chemical irritants (eg, gold, iodides) as well as bacteria (streptococci, staphylococci, gonococci, C. diphtheriae). Fever, lymphadenopathy, and malaise may occur, or the infection may be localized.

Mucosal lesions accompanying systemic disease include the mucous patches of syphilis; the strawberry, then raspberry, tongue of scarlet fever, Koplik’s spots of meales; the ulcers of erythema multiforme; and the smooth, fiery red tongue and painful mouth of pellagra. Hemorrhagic lesions may occur in scurvy and disorders of platelet number and function. Unprovoked bleeding, decreased salivation, and an ammonia-like odor accompany uremic stomatitis.

The mucocutaneous lymph node syndrome (Kawasaki syndrome) affects children, causing erythema of the lips and oral mucosa.

Acrodynia occurs in children and is characterized by oral ulcerations, profuse salivation, and bruxism with loss of teeth. It is caused by a mercurial toxicity reaction.

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Diagnosis of Stomatitis

Establishing the cause may be difficult. The history may disclose a systemic disease, a dietary deficiency, or contact with irritants or allergens. Physical examination is obligatory, since it may reveal lesions of other mucous membranes, as in erythema multiforme, candidiasis, or syphilis; lesions of the skin, as in pellagra, pemphigus, lichen planus, or SLE; signs of pulmonary TB, sprue, anemia, or another contributory disease; or a general decrease in exocrine secretions.

Directsmearsandculturesfromthelesionsmaydiscloseapathogen. Any diphtheria-like membrane should be so examined promptly. ANUG usually limits itself to the gingival tissue, differentiating it from primary herpetic gingivostomatitis. Dark field examination of scraping from the lesions and STS are indicated in an attempt to rule out syphilis before penicillin is given. In candidiasis, a history of recent antibiotic or corticosteroid therapy is common. To identify C. albicans, one should culture and microscopically examine scrapings from suspect lesions in 10% potassium hydroxide hanging drop preparations or methylene blue-stained smears. Blood count, bone marrow examination, gastric analysis, or other laboratory procedures may be indicated.

A solitary, undiagnosed oral lesion of > 1 wk duration that does respond to treatment must be considered malignant until biopsy proves otherwise.

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Treatment of Stomatitis

Underlying systemic disorders should be treated specifically. Meticulous oral hygiene is always necessary. Candidiasis usually responds to nystatin oral suspension 400,000 u. (4 ml) qid for 10 days as an oral rinse and then swallowed. Clotrimazole 10-mg oral lozenges 5 times a day for 14 days are effective in persistent overgrowths. When compliance is a problem, ketoconazole one 200-mg tablet (for children < 12 yr, ¼ tablet) orally once a day is effective. All antifungals should be continued for at least 3 days after symptoms and signs disappear. For oral bacterial infections, penicillin V 500 mg orally qid for 10 days is the drug of choice. Large, painful ulcers that prevent eating may be relieved temporarily by rinsing the mouth with 2% lidocaine viscous 15 ml (1 tbsp) before each meal and q 3 h as needed for relief. A mouthwash of ½ tsp sodium bicarbonate in 250 ml (8 oz) warm water qid is soothing and cleansing. Rinsing (and spitting out) after each meal with elixir of dexamethasone 0.5 mg/5 ml (1 tsp) relieves discomfort and promotes healing of nonviral and nonbacterial oral lesions.

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